BlueCross G06L $35 PCP Copay + $0 Virtual Care for Medical & Mental Health – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $3,000 per person $3,000 per person |
| Out-of-pocket max | $6,600 per person $13,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $750 copay after deductible, 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $8 copay |
| Brand | $35 copay |
| Non-preferred Brand | $60 copay |
| Specialty | $120 copay |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbst.com/sbc/2024/127600/G06L_SBC.pdf |
| Drug and medication plan formulary | https://www.bcbst.com/docs/providers/2024-essential-formulary.pdf |
| Search doctor list | https://www.bcbst.com/network-l |
